Percentage of patients aged 3 through 17 years of age, who undergo general anesthesia in which an inhalational anesthetic is used for maintenance AND who have one or more risk factors for post-operative vomiting (POV), who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively and/or intraoperatively.

The purpose of this process of care measure is to reduce the incidence of postoperative nausea and vomiting in pediatric patients.

Postoperative nausea and vomiting (PONV) is a common and unpleasant outcome of anesthesia care that can lead to other complications, lengthening the patient’s recovery period after surgery². Effective management of PONV leads to optimal patient outcomes and comfort during the postoperative period.³ Combination therapy that includes two prophylactic pharmacologic anti-emetic agents of different classes is most effective when managing PONV in children.^4,5

A separate PONV risk model should be considered for pediatric patients as many proven risk factors for adults are difficult to assess or do not apply to children.⁶ The independent PONV risk factors identified for pediatrics include duration of surgery greater than 30 minutes, age greater than 3 years old, positive history of PONV (individual and/or immediate family) and strabismus surgery.⁶ Although including a prophylactic anti-emetic administration protocol that considers such risk factors has shown to reduce the incidence of PONV, there is high variability in this outcome.^7,8

4 hours before Anesthesia Start to PACU Start

All patients, age 3 through 17 years of age, who undergo any procedure under general anesthesia in which an inhalational anesthetic is used for maintenance AND who have one or more additional risk factors for POV.

POV Risk Factors:

• History of POV or Post-Operative Nausea and Vomiting (PONV) in patient, parent or sibling
• Procedure Type: Strabismus
• Surgery ≥ 30 minutes (determined by Case Duration)

• Patients < 3 or > 17 years old.
• Patients transferred directly to the ICU
• Procedure Type: Liver Transplant 
• Procedure Type: Lung Transplant 
• Labor Epidurals as determined by Obstetric Anesthesia Type 
• Procedures on the Neck (CPT 00326)
• Intrathoracic Procedures (CPT 00561)
• Procedures on the Lower Abdomen (CPT 00834)
• Endoscopy (CPT 00740, 00810)
• Obturator neurectomy (CPT 01180, 01190)
• Shoulder cast application (CPT 01682)
• Cases in which an inhalation anesthetic is used only for induction (Halogenated Gases Used and Nitrous Oxide Used)

Patient receives combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively or intraoperatively

Anti-emetic therapy:  The recommended pharmacologic anti-emetics for PONV prophylaxis in pediatric patients at risk for moderate to severe PONV include (but may not limited to):

• 5-Hydroxytryptamine (5-HT3) Receptor Antagonists (Recommended as the first choice for prophylaxis for POV in children)
• Glucocorticoids
• Anticholinergics
• Antihistamines
• Butyrophenones
• Phenothiazines
• Phenylethylamines
• NK-1 Receptor Antagonists

Note: In addition, propofol infusion is accepted as one of the antiemetic options for this measure. The foregoing list of medications/drug names is based on clinical guidelines and other evidence. The specified drugs were selected based on the strength of evidence for their clinical effectiveness. This list of selected drugs may not be current. Physicians and other health care professionals should refer to the FDA’s web site page entitled “Drug Safety Communications” for up-to-date drug recall and alert information when prescribing medications.

• For a case to be included for the PONV 02 measure, the patient must have received inhalational general anesthetic for maintenance purposes AND have two or more risk factors for POV. This measure determines maintenance using the Halogenated Gases Used and Nitrous Oxide Used phenotypes and must return value code > 1.

• Values for flows and gases will be assessed and considered artifact if less than the following ranges and the patient did not receive any other inhalational general anesthetics greater than these ranges:

  • Nitrous Oxide Flows: <0.2 L/min
  • Isoflurane Insp %: <0.3%
  • Sevoflurane Insp %: <0.4%
  • Desflurane Insp %: <1.2%
  • Nitrous Oxide Insp % <20%

Provider(s) signed in at Induction End.

Method for determining Responsible Provider:

1. Provider signed in at Anesthesia Induction End. If not available then,
2. Provider signed in at Anesthesia Induction Start. If not available then,
3. Provider signed in at Surgery Start. If not available then,
4. Provider signed in at Patient in Room. If not available then,
5. Provider signed in Anesthesia Start.

1. Gan TJ, Meyer TA, Apfel CC, et al. Society for Ambulatory Anesthesia guidelines for the management of postoperative nausea and vomiting. Anesthesia and analgesia. 2007;105(6):1615-1628, table of contents.
2. Gillmann HJ, Wasilenko S, Zuger J, et al. Standardised electronic algorithms for monitoring prophylaxis of postoperative nausea and vomiting. Archives of medical science : AMS. 2019;15(2):408-415.
3. Collins AS. Postoperative nausea and vomiting in adults: implications for critical care. Critical care nurse. 2011;31(6):36-45.
4. Gan TJ, Diemunsch P, Habib AS, et al. Consensus guidelines for the management of postoperative nausea and vomiting. Anesthesia and analgesia. 2014;118(1):85-113.
5. Shen YD, Chen CY, Wu CH, Cherng YG, Tam KW. Dexamethasone, ondansetron, and their combination and postoperative nausea and vomiting in children undergoing strabismus surgery: a meta-analysis of randomized controlled trials. Paediatric anaesthesia. 2014;24(5):490-498.
6. Eberhart LH, Geldner G, Kranke P, et al. The development and validation of a risk score to predict the probability of postoperative vomiting in pediatric patients. Anesthesia and analgesia. 2004;99(6):1630-1637, table of contents.
7. De Oliveira GS, Jr., Castro-Alves LJ, Chang R, Yaghmour E, McCarthy RJ. Systemic metoclopramide to prevent postoperative nausea and vomiting: a meta-analysis without Fujii's studies. British journal of anaesthesia. 2012;109(5):688-697.
8. Schraag S, Pradelli L, Alsaleh AJO, et al. Propofol vs. inhalational agents to maintain general anaesthesia in ambulatory and in-patient surgery: a systematic review and meta-analysis. BMC anesthesiology. 2018;18(1):162.